Prescribing in dementia

It is important to remember that symptoms of stress and distress in dementia are often a temporary phenomenon or a result of external influences.

‘Watchful waiting’ and non-pharmacological interventions should be considered and possible physical causes of deterioration should be ruled out before prescribing antipsychotics.

If required for acute distress/agitation/anxiety, consider short-term use of ‘as required’ benzodiazepines prescribed at the lowest effective dose e.g. lorazepam 500micrograms (maximum 2mg over 24 hours). Clearly document the reason for use and outcome. There is no evidence base supporting the long-term regular use of benzodiazepines for symptoms of stress and distress in dementia

Do Not Initiate Antipsychotics In The Following Circumstances:

Antipsychotic medication use in older people with dementia is associated with an increased risk of stroke and death. In addition, all antipsychotics have significant adverse side effects. They should only be used as a last resort for specific symptom(s) for a specified time period, with regular monitoring of effect and any adverse effects:

• It is not appropriate to initiate antipsychotic medication to manage symptoms which are unlikely to be modified by antipsychotic medication e.g. wandering, repetitive vocalisation, sleep disturbance, repetitive questioning.
• It is not appropriate to initiate antipsychotic medication when the symptoms can be managed effectively by non-pharmacological methods such as person-centred care. Ensure non-pharmacological approaches have been properly implemented, evaluated and documented before initiating antipsychotic medication.
• If other possible causes have not been investigated e.g. physical causes, psychological causes and environmental factors before initiating antipsychotic medication (Appendix II- Quick Reference Guide).

When to Initiate Antipsychotic Medication:

It may be appropriate to initiate medication where:

• The person with dementia is distressed by the target symptoms.
• The health or safety of the person with dementia is compromised by the severity of the symptoms or the safety of others is at risk.
• There has been an adequate analysis of the potential risks and benefits.

Antipsychotic treatment may be effective for psychosis, persistent physical aggression or severe agitation. It may be appropriate to consider a short course of antipsychotic in delirium. See NHS GGC Delirium Diagnosis, Risk Reduction and Management in Acute Services for further information.¹

The most important adverse effects associated with antipsychotic use in patients with dementia are Extrapyramidal Side Effects, falls, postural hypotension, dehydration, constipation, chest infections, ankle oedema, deep vein thrombosis/pulmonary embolism, cardiac arrhythmia/MI and stroke (highest risk in the first four weeks of treatment).

Patients should be kept well hydrated and as mobile as possible.

The consideration of these potential adverse effects and decisions regarding treatment choice should be clearly documented.

Medication initiation and changes to medication must be discussed with the patient if they have capacity. Where capacity is absent and there is an existing legal proxy i.e. welfare attorney or guardian, the decision to prescribe must be discussed with them, risks outlined and agreement sought. (See Appendix III for patient and carer information leaflet)

Patient information leaflets for the use of specific medications are available on the Choice and Medication. An information guide for medication used for symptoms of dementia is also available from Alzheimer’s Society.

If the patient lacks capacity and if there is no formal legal welfare proxy, the principles of the Adults with Incapacity (Scotland) Act 2000 apply and treatment options should be discussed with relevant others, such as next of kin, carer or patient advocate. In either circumstance, an appropriate Section 47 certificate of incapacity is required.

If a patient is subject to the Mental Health (Care and Treatment) (Scotland) 2003 Act, check that any psychotropic medication is included on a current T2B/T3B certificate.

Antipsychotics should be commenced at the lowest possible dose, titrated carefully and reviewed within the first four weeks and after 6-12 weeks.

At review, discontinuation of the antipsychotic should be considered unless there is ongoing significant risk and/or distress.

The antipsychotic prescribing in dementia initiation and review form should be used when commencing treatment and for review throughout treatment (appendix IV of guideline)

Licensed treatment

Risperidone is licensed for the short-term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer's dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others.

The BNF dose in this case is 250micrograms twice daily increased according to response.

The usual dose is 500micrograms twice daily. (Maximum 1mg twice daily).³

Consider a lower starting dose of 250micrograms once daily. This can be effective and may be more appropriate for those frailer patients who are at higher risk of adverse effects.

The management of physical health care of older patients differs to that of a younger population for the following reasons:

• Bioavailability of medication
• An increase in the sensitivity to medication effects
• Increased frailty and multi-morbidity.

The older adult patient should receive the same standard of physical health care as that of the younger adult, paying attention to these special features. Monitor for common side effects such as extrapyramidal side effects, antimuscarinic effects (especially constipation) and effects on blood pressure and biochemistry. Refer to Physical Healthcare Policy for further information.

Where appropriate and practical, ECGs should be completed at baseline and thereafter when clinically indicated. Abnormalities should be acted on according to significance and clinical indication. Consult with cardiologist if in doubt. See NHS GGC MU Extra Drug Induced QT Prolongation for further information on QT prolongation.²

The use of antipsychotic medication for the treatment of symptoms of stress and distress in patients with Lewy Body disease should generally be avoided as risks are greater in this patient group. In dementia with Lewy bodies and Parkinson’s disease (PD) dementia the limited evidence supports the use of cholinesterase inhibitors to target psychotic symptoms. It is acknowledged however that for more severe psychotic symptoms that have not responded to a cholinesterase inhibitor, a cautious trial with an antipsychotic may be required. First generation antipsychotics e.g. haloperidol should be avoided.

The fourth report of the Dementia with Lewy Body (DLB) Consortium⁴ suggests that low dose quetiapine may be relatively safer than other antipsychotics in DLB. Aripiprazole has theoretical advantages over conventional antipsychotics in DLB and is occasionally used in practice, however, the updated DLB Consortium did not recommend its use.

The use of antipsychotics in DLB is off-label. When commencing antipsychotic treatment for DLB or PD dementia, ‘start low and go slow’ e.g. 12.5mg quetiapine.

On rare occasions when above antipsychotics have not been effective clozapine could be considered. It is strongly advised that before clozapine is started that advice is sought from specialist mental health pharmacist.

*risperidone licensed for short term management of Alzheimer’s dementia

** anecdotal evidence for use of aripiprazole in DLB and PD dementia

*Adapted from NHS Scotland polypharmacy guidance 2018

Antipsychotics have only limited benefit in treating symptoms of stress and distress in older people with dementia and carry significant risk of harm e.g. delirium, cerebrovascular events, falls and all-cause mortality.

Medication and management of stressed and distressed behaviours:

• Medication should be used as last, not first resort, to manage stress and distress
• People with dementia on psychotropic medicines should be prioritised for multidisciplinary review
• People with dementia on psychotropic medicines should be reviewed every three months
• Psychotropic medicines should be withdrawn gradually

Which patients should be prioritised for review?

Patients who have dementia and who have been on antipsychotics for more than 3 months and have stable symptoms should be reviewed by initiating team or in consultation with mental health services with a view to reducing or stopping antipsychotic medication. Priority groups for reducing antipsychotic medication include:

• People in care homes ( see NHS GGC Clinical Guideline Psychotropic Medicines Reviewing with Care Home Residents⁶ for support in reviewing psychotropic medications other than antipsychotics)
• People with vascular dementia
• People with dementia plus history of cardiovascular disease

When should antipsychotic medication NOT be stopped?

Patients who have a co-morbid mental illness that is treated with antipsychotic medication, such as schizophrenia, persistent delusional disorder, psychotic depression or bipolar affective disorder should not have antipsychotic medication reduced without specialist advice.

How to reduce antipsychotic medication? (Also see Antipsychotic Review Flowchart)

• Slow reduction (25% daily dose) with close monitoring
• Review the effect after one week to assess for: the re-emergence of the initial ‘target’ symptoms of stress and distress
• Discontinuation symptoms include nausea, vomiting, anorexia, diarrhoea, rhinorrhoea, sweating, myalgia, paraesthesia, insomnia, restlessness, anxiety and agitation. Generally begin within 1 to 4 days of withdrawal and abate within 7 to 14 day
• If either of the above occurs the clinician should make an assessment of the risks and benefits of re-instating the previous dose of antipsychotic. Further attempts to reduce the antipsychotic should be made one month later with smaller decrements (10% daily dose)
• If there are no particular problems after week 1 then the dose should remain the same with further review after week 2 to 4 weeks
• If the reduction has been tolerated without any of the effects described above then reduce by a further 25% and repeat the process
• There may be practical issues when reducing the dose, for example the availability and form of small doses of medication. It is recommended that this is discussed with a pharmacist
• It is suggested that once the total daily dose is reduced to the recommended starting dose for the individual antipsychotic, it may be stopped
• Review any other medication prescribed for antipsychotic side effects as they may no longer be required once the antipsychotic has been stopped

Flowchart currently unavailable. Refer to full guidance

1. NHS GGC Clinical Guideline Delirium Diagnosis, Risk Reduction and Management in Acute Services. March 2018
2. NHS GGC Medicines Update Extra Drug Induced QT prolongation. Issue 8. Jul 2018
3. British National Formulary BNF76. Sep18-Mar19
4. McKeith IG, Boeve BF, Dickson DW, Halliday G, Taylor JP Neurology. 2017 Jul 4;89(1):88-100. et al. Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium.
5. NHS Scotland Polypharmacy Guidance Realistic Medicine 3^rd Edition 2018
6. NHS GGC Clinical Guideline. Psychotropic Medicines Reviewing with Care Home Residents. May 2017